The Relationship between Hope and Self-Esteem in Patients with Leukemia

1Department of Medical-Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran 2Department of Medical-Surgical Nursing, Hematology and Oncology Research Center, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran 3Liver and Gastrointestinal, Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 4Department of Nursing, Faculty of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran


Introduction
Cancer is a life-threatening disease and in many cultures was perceived as incurable. 1ematologic malignancies represent the fifth most common diagnosed cancer type.It is estimated that there were 150,000 new cases of lymphoma, multiple myeloma, and leukemia diagnosed in the U.S. in 2012, which resulted in nearly 55,000 deaths. 2 In Iran, the incidence of leukemia in women and men 15-49 years, was 13.89% and 18.31% in 100,000, respectively.It has been estimated that leukemia's account for 4.89% of all the cancers in Iranian men. 3 Leukemia is a cancer of the bone marrow and blood.The four major types of leukemia are acute myeloid leukemia, chronic myeloid leukemia, acute lymphoblastic leukemia and chronic lymphocytic leukemia. 46][7] It seems that disclosure of cancer has negative effects on cancer patients. 8oreover, patients with hematological malignancies are often treated Copyright © 2015 by Tabriz University of Medical Sciences with intensive anti-neoplastic regimens that may continue for many years and even until the last days of life. 9Hope is one of important sources that can helps cancer patients cope more efficiently at all stages of the disease. 10ope is a multidimensional and dynamic construct which has been defined as the possibility of a better future from an uncertain present. 11Literature revealed that hope is an important factor in the recovery of cancer patients 12 Cancer patients appears to be more influenced by the level of hope than other diseases. 13For example as hopelessness is a risk factor for suicide 14 thus, identifying factors that affects the hope of cancer patients specially newly diagnosed patents is of great importance.
Hope involves of positive thinking towards the future and the desire to make an effort for life. 15Regarding the importance of hope in leukemic patients, there are inadequate studies which examined the hope in Iranian cancer patients. 12s self-esteem is a complex structural concept, there is no consensus regarding its definition. 16For example in sociology and psychology, self-esteem reflects a person's overall emotional evaluation of his or her own worth.It is a judgment of oneself as well as a feeling toward the self.Self-esteem includes beliefs (for example, "I am successful," "I am respected") and emotions such as triumph, despair, pride and shame. 17t also has been defined as a relationship between self-image and the ideal-self of a person. 18self-esteem plays an important role in the process of encountering and coping with the diseases.Deteriorated self-esteem is a common feeling among cancer patients. 19ope and self-esteem as the symbols of spiritual dimension are usually associated with persons' physical and mental health. 20It is necessary to pay more attention to emotional reactions of patients with hematologic malignancies in nursing care agencies. 21Although some studies have been conducted regarding the association of these concepts in patients with hematologic malignancies, there are inadequate studies which examined this relationship 22 among Iranian cancer patients.Accordingly, the aim of this study was to examine the relationship of hope and self-esteem among hematologic cancer patients in Iran.

Materials and methods
This descriptive-correlational study was conducted in oncology wards of Shahid Ghazi Tabatabai hospital affiliated to Tabriz University of Medical Sciences, Tabriz, Iran.The sample size (n=85) was calculated based on a pilot study of 30 patients.Participants were selected using consecutive sampling method.The study population included all the patients who admitted to this hospital and met the following criteria: (a) having confirmed cancer diagnosis; (b) be at least 14 years old; (c) willing to participate in the study; and (d) lack of mental illness such as depression and physical or mental disability.
The data collection tools composed of three parts.The first part included a demographic and social check list which designed to collect some participants' properties such as age, gender, education, economy, job, marital status, type and duration of treatments, etc.
The second part included Herth Hope Index (HHI).This scale has 12 items classified according to a four-point Likert scale ranging from 1(not true at all) to 4 (always true).Two of the items (3 and 7) are scored in the reverse.The total scores of HHI ranging from 12 to 48 points; the higher the score, the greater the level of hope. 23This scale has been used in some Iranian studies. 21The third part of instrument was coppersmith self-esteem Inventory consisted of 35 items classified according to a four-point Likert scale ranging from 1 to 4. The total scores of Coppersmith self-esteem Inventory ranging from 35 to 140 scores; the higher the score, the greater the level of self-esteem. 24he scales face and content validity were assessed and verified by the expert panel constituted 13 members of Tabriz University of Medical Sciences.HHI has been used successfully in other studies in Iran.The reliability co-efficient using test re-test in cancer patients for HHI (Persian form) was 0.84 in one study. 22The reliability of Coopersmith self-esteem Inventory (Persian form) also confirmed by Ansari Jaberi et al. 25 Before the data collection, the study proposal was approved by the regional ethics committee of Tabriz University of Medical Sciences.Patients who met criteria for the study were identified and all eligible patients were invited to participate.After being presented basic information, patients who were willing to participate were asked to participate in a private interview for data collection.All patients who participated in the study gave informed consent.
Data were analyzed using SPSS version 13.Descriptive statistics such as the mean (standard deviation) were used to describe demographic data and levels of hope and self-esteem among patients.Regression models and Spearman's Correlation coefficient (rs) were used to analyze the associations between patients' hope and selfesteem.P < 0.05 was considered significant.

Results
The majority of the participants were male, married, had high school and low economic status, and also were admitted to the hospital for chemotherapy (Table 1).
As shown in Table 2, the mean and standard deviation of hope and self-esteem levels were 33.05 (5.24) and 94.61 (11.51), respectively.There was no significant correlation between hope and demographic variables, as well as between self-esteem and these variables using Regression analysis (Tables 3).There was a strong positive correlation between the hope and self-esteem variables using the Spearman's correlation coefficient (rs = 0.73, n = 85, P < 0.001).

Discussion
According to the main objective of this study, the findings showed that there was a positive correlation between hope and selfesteem in Iranian leukemic patients.However, there were no significant correlations between any of demographic variables with hope and self-esteem scores.Similar to our findings in another study in Iran researchers found no significant differences between any of demographic variables and self-esteem. 25So the selfesteem of male leukemic patients had no significant correlation with any of mentioned individual variables.However, for female patients, this correlation was positive because most of them had been cared by someone in the home.
The study findings showed leukemic patients had moderate to high levels of hope.Some other national studies have been reported similar findings. 12,25,26So, the finding of this study highlighted the importance of existing evidence.The findings of studies in other countries also revealed that most of cancer patients had moderate to high levels of hope.For example in a study in Norway, 59.5% of cancer patients reported modest level of hope. 27The findings of another study showed that Taiwanese cancer patients had moderate levels of hope. 28High level of hope among cancer patients can be explain by this hypothesis that depressed and anxious cancer patients with low hope levels usually are not willing to participate in such studies. 29It seems that when people are faced with life threatening diseases gradually find cognitive compatibility and reorganize their values. 29It seems that however the primary hope level reduces in the process of these changes, cancer patients still expect to be treated.In this study we did not examined whether the participated patients had been informed to their diagnosis which may also explain their moderate or high levels of hope.
However, the findings of studies in some Western countries showed that being informed to cancer diagnosis had no adverse effects on the patients hope and in some cases such informing had an increasing effect on the patients' level of hope. 30he study findings also showed leukemic patients had moderate level of self-esteem.A few studies had focused on self-esteem in patients with cancer. 31Similar to our findings in another study in Iran, the cancer patients in both genders had moderate level of self-esteem. 32his study also showed that there was a positive numerical correlation between the patients hope and self-esteem.Similarly, the findings of a study in Italia also showed a positive correlation between hope and selfesteem in cancer patients. 21he findings of this study showed that self-esteem was one of the factors that could affect patients' level of hope.Although culture may determines the different ways that patients understand cancer, but it seems that self-esteem and hope relationship could be similar in different cultures.Despite the strength of this study, it also has some limitations.First, the patients' answers to scale items might be affected by their physical fatigue and mental status.However, this limitation resolved to some extent by postponing the meeting for data collection to subsequent sessions.Furthermore, this study was done in oncology wards of Shahid Ghazi Hospital in Tabriz, which is not representing variations of all the country population.

Conclusion
The findings of the present study have shown that there was a positive correlation between hope and self-esteem in Iranian cancer patients.The study findings could be helpful for nurses through designing appropriate educational programs for maintaining and promoting hope and selfesteem among leukemic patients.Although culture determines the different ways that patients understand cancer, but it seems that the self-esteem and hope relationship could be similar in different cultures.In relation to future research, replicating such studies with better sampling methods in other Iranian cultures as well as Middle East countries are required.

Table 2 .
Patients' mean and standard deviation of hope and self-esteem

Table 3 .
The association between hope and Self-steem some demographic variables